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Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes (ARMADILLO) Study View project
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Reducing maternal mortality is the and national professional organiza- indicators enables assessments of the
Millennium Development Goal 5. To tions including the Royal College of quality of care provided to pregnant
reach this goal, countries need an accu- Obstetricians and Gynaecologists, the women.
rate picture of the causes and levels of American College of Obstetricians The WHO technical working
maternal deaths. Recent systematic re- and Gynecologists and the Canadian group recommends that the new
views have shown that there are many College of Obstetricians and Gynae- maternal death classification system
inconsistencies in the way maternal cologists. Revised after this feedback, be adopted by all countries and the
deaths are classified and there is a lack the second version was tested on eight maternal near-miss approach be con-
of standard definitions and criteria for databases of maternal deaths: national sidered in national plans for improving
identifying severe maternal morbidity databases from Colombia, Jamaica and maternal health. By using the same
and near-miss cases.1,2 South Africa, other databases from classifications, reliable comparisons can
WHO established a techni- Kenya, Malawi and Zimbabwe and be made within and between countries
cal working group of obstetricians, verbal autopsy data from Afghanistan and regions. Applying this classifica-
midwives, epidemiologists and public and Nigeria. All sites found the clas- tion should help to identify the health
health professionals from developing sification workable and useful. system shortfalls that countries need to
and developed countries to develop a The new WHO classification of address in order to reduce complica-
maternal death classification system. cause of maternal death has a sim- tions and fatal outcomes of pregnancy
The group established three prin- ple structure to facilitate tabulation: and childbirth. ■
ciples for its work. First, the classifica- group, disease category and individual
tion must be practical and understood underlying causes. The group includes Acknowledgements
by its users (clinicians, epidemiologists three categories: direct maternal Available at: http://www.who.int/bul-
and programme managers), Second, deaths, indirect maternal deaths and letin/volumes/87/10/09-071001/en/
underlying causes must be exclusive of “unanticipated complications of index.html
all other conditions; as in the Inter- management”. This addition makes it
national Statistical Classification of possible to track trends in iatrogenic References
Diseases and Related Health Problems disease as, for example, related to 1. Khan KS, Wojdyla D, Say L, Gulmezoglu
(ICD), the underlying cause is the caesarean sections. Underlying causes AM, Van Look PFA. WHO analysis of causes
disease or injury which initiated the are clearly separated from conditions of maternal deaths: a systematic review.
Lancet 2006;367:1066-74. PMID:16581405
sequence of events leading directly to contributing to fatal outcomes. Finally, doi:10.1016/S0140-6736(06)68397-9
death, or the circumstances of the ac- the working group decided to clas- 2. Say L, Pattinson RC, Gülmezoglu AM. WHO
cident or violence which produced the sify suicide in pregnancy, deaths from systematic review of maternal morbidity and
fatal injury. Third, the new classifica- puerperal psychosis and postpartum mortality: the prevalence of severe acute
tion system should be compatible with depression in the category of direct maternal morbidity (near miss). Reprod Health
and contribute to the 11th revision of maternal deaths.3 2004;1:3. PMID:15357863 doi:10.1186/1742-
4755-1-3
the ICD. Incorporating this maternal The working group also reached
3. Report on the World Health Organization
death classification into the ICD will consensus on how to define maternal Working Group on the Classification of Maternal
encourage consistent use in both death near miss – “a woman who nearly Deaths and Severe Maternal Morbidities.
certificates and confidential enquiries died but survived a complication that Geneva: World Health Organization; 2009.
into maternal deaths, and improve the occurred during pregnancy, childbirth 4. Say L, Souza JP, Pattinson RC. Maternal near
comparability of data. or within 42 days of termination of miss – towards a standard tool for monitoring
The proposed maternal death clas- pregnancy”.4 Signs of organ dysfunc- quality of maternal health care. Best Pract
Res Clin Obstet Gynaecol 2009;23:287-
sification system was sent to more than tion that follow life-threatening condi-
96. PMID:19303368 doi:10.1016/j.
40 individual reviewers and the Inter- tions are used to identify maternal near bpobgyn.2009.01.007
national Federation of Gynecology and misses so that the same classification
Obstetrics, the United Nations Chil- of underlying causes is used for both
dren’s Fund (UNICEF), the United maternal deaths and near misses. This
Nations Population Fund (UNFPA) consistency and a set of near-miss
a
MRC Maternal and Infant Health Care Strategies Research Unit, University of Pretoria, Gauteng, South Africa.
b
Department of Reproductive Health and Research, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland.
c
Liverpool School of Tropical Medicine, Liverpool, England.
d
Office for National Statistics, London, England.
Correspondence to João Paulo Souza (e-mail: souzaj@who.int).
Acknowledgements
The following individuals were among
the members of the expert group that
developed the identification crite-
ria for maternal near miss: Affette
McCaw-Binns, Anoma Jayathilaka,
Buyanjargal Yadamsuren, Cleone
Rooney, João Paulo Souza, José
Guilherme Cecatti, Lale Say, Linda
Bartlett, Mary Ellen Stanton, Mohamed
Cherine Ramadan, Nynke van den
Broek, Robert C Pattinson, Rogelio
Gonzalez,Veronique Filippi. We thank
Ahmet Metin Gülmezoglu, Jelka
Zupan, and Vicky Camacho for their
contribution. This work was funded by
USAID and UNDP/UNFPA/WHO/
World Bank Special Programme of
Research, Development and Research
Training in Human Reproduction
(HRP).